HomeMy WebLinkAbout9535AIORKERS' COMPENSATION DECLARATION
I hereby -affirm that I have a certificate of consent to self
insure, or cern}icate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, lob.C.)
Policy No7 7 9%-0-ompany .V,—ac 1:—two
QCertified copy is hereby furnished.
Cer)ified copy is filed with the county building inspec-
lion department. /
Date' 4? Applicant 0!y6j C6 L:; •V i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars (SI00) or less.)
I cerlify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, offer making this Certificate of
Exemption, you should become subject to the Workers'
Compansation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and affect.
License Number/S-7 6 S/ Lic. ClassS
Contractor / IFtiLd _ Gs» 4 Date a 7
1 am exempt under Sec.
B.BP.C. for this reason
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professloms Code):
O1, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
0 I,as owner of the property, am exclusively contractingwithlicensedcontractorstoconstructtheproject (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
tender's Name
lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
111er-1eec 7-142
Signa•ure of Applicant or Agent Dob
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APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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CITY C[- CLA55 113 BK PG VALIDATION
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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